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08/09/2004 15: 30 4640138 tNViKUNMLNIAL HLALIH t-AUL t71 <br /> SAN.JOAQUIN "" )UNTY ENVIRONMENTAL REALTI4'NF,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rc0•() <br /> OWNER I OPERATOR CHECK if BILLIN©ADDRESS❑ <br /> &' WC-5T 60AS l <br /> FACiLn NAME Meo -;t &OeO <br /> SITE ADDRESS Iq ✓EMLIC 74/Z 10 <br /> Street Number DircetIon rrc Name I Code <br /> HONiE or MAILING ADDRESS (if Different from Site Address) <br /> 5 et Number Stre <br /> CITY STATE ZIP <br /> PHONE#1 <br /> ExT, APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Pa Nuc q -K c`- <br /> CHECK if BILUNG ADDRESS❑ <br /> `/� <br /> PHONE# EXT.BUSINESS NAME (I 1 Vt P O�ME>[�L SyS�"715 "7l� 5�7-C,4w <br /> HOME or MAILING ADDRESSFAX# <br /> )JC-ViL-LE 51- ( 1/4 ) <br /> CrNSTATE C`A ZIP C/10 l05 <br /> BILLING ACKN WLEDGEMENT: I., the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVTR.ONMENTAL HEALTH DP..PARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business is identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUTN <br /> COUNTY Ordinance Codes.Standards,STATE and FEDERAL IaWS. <br /> APPLICANT'S SIGNATURE: r �i <br /> PROPERTY/BUSINUS OWNER❑ OPETOR/MANAGER ❑ OTHER AxmTORIZED AGENT ill' <br /> T6 1 L'DO/1 2�, <br /> Tf APPLICANT iS'not the BILLING PAR 1'T'proof of authorization to Sign is required Title <br /> A11HORIZATIO TOLEASE 114E RMA'I'ION: When applicable, I, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN 70AQUIN COUNTY ENVIRONMENTAL HRALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> n -1 e� <br /> TYPE OF SERVICE REQUESTED: ; 1ST 1�-� TJL-- <br /> COMMENTS: EC �� <br /> R �Ac a Cho) VAPoet�s5 �DZdoo /s-�4(L Di;r�-c�,tPs 6 <br /> 10-IS o� lnI Pf�ES�IG� GF /�l�PcC�Q- SiUc`rl SNl 11 • rs 40 <br /> 2 <br /> N A��JQI OVEN <br /> Ty p0NtitFcot jjV <br /> EMPLOYEE#: DA �7nC)' J t U <br /> ACCEPTED BY: U Li U 9 I If-A <br /> EMPLOYEE M DATE: <br /> ASSIGNED TO: <br /> Date ServiCe Completed (if already completed): <br /> SERVICE CODE: <br /> Fee Amount: �'� j. C J <br /> Amount Paid Payment Date /p �9 D <br /> Received By: <br /> Payment Type Invoice# Check# + <br /> SR FORM(Golden Rd ) <br /> EHD 48-02.025 <br />